What is the initial treatment for seizures in a patient with a brain tumor who has developed a venous infarct?

Treatment of Seizures in Brain Tumor Patients with Post-Surgical Venous Infarct

Initiate levetiracetam as first-line monotherapy at 1000-3000 mg/day in divided doses for seizure control in this patient. 1

Initial Management Approach

Start anticonvulsant therapy immediately since this patient has experienced seizures following brain tumor surgery complicated by venous infarct. 1 The vast majority of brain tumor patients who experience a seizure should be placed on anticonvulsant secondary prophylaxis, at least transiently. 1

First-Line Drug Selection

Levetiracetam is the preferred first-choice agent for the following reasons:

• Has become the drug of first choice at most neuro-oncology centers due to efficacy and overall good tolerability 1
• Lacks enzyme-inducing properties, avoiding drug interactions with steroids and cytotoxic agents that are commonly used in brain tumor patients 1
• Available in both IV and oral formulations, allowing seamless transition in the perioperative period 2, 3
• No increased bleeding risk, which is particularly relevant given the venous infarct complication 1

Dosing Strategy

Initial dosing for levetiracetam:

• Start at 1000 mg/day divided twice daily 2, 3
• Can titrate up to 3000 mg/day based on seizure control 1, 2
• Studies show 88-100% seizure freedom rates in the post-surgical period with this regimen 3, 4

Alternative Options if Levetiracetam Fails or is Contraindicated

Important caveat: Levetiracetam can cause psychiatric side-effects in some patients, which remains a concern. 1 If the patient has pre-existing psychiatric comorbidities or develops intolerable psychiatric effects, consider:

Second-Line Alternatives:

• Lamotrigine: Good antiseizure activity but requires several weeks to reach therapeutic levels 1
• Lacosamide: May serve as add-on treatment if monotherapy fails 1
• Valproic acid: Still has a firm place with good efficacy and tolerability, but must not be used in females of childbearing potential and requires monitoring for drug interactions 1

Drugs to Avoid

Do not use enzyme-inducing anticonvulsants in this patient: 1

• Phenytoin
• Phenobarbital
• Carbamazepine

These are no longer recommended as first-choice agents due to their side-effect profile and significant drug interactions with steroids and various cytotoxic/targeted agents. 1

Duration of Therapy

Continue anticonvulsant therapy until local control is achieved. 1 Given the venous infarct complication, this patient will likely require longer-term therapy than those with uncomplicated resections. If near gross total resection was achieved without recurrent tumor growth, tapering can be considered within weeks after surgery. 1

Monitoring Requirements

• Question about seizure occurrences at each follow-up visit 1
• Consider serum drug levels to assess compliance and explore failure to control seizures 1
• Obtain repeat MRI if seizures worsen, as this often heralds tumor progression 1
• Rule out nonconvulsive status epilepticus with EEG if there are worsening neurological symptoms or vigilance problems 1

Critical Pitfalls to Avoid

• Do not use prophylactic anticonvulsants in brain tumor patients who have not had seizures (primary prophylaxis is not indicated) 1
• Avoid valproic acid in women of childbearing age due to teratogenicity 1, 5
• Monitor for psychiatric side effects with levetiracetam, particularly mood changes and behavioral disturbances 1, 6
• Check for drug interactions regularly if using valproic acid or other agents 1